sign in sign up
<<
Home , Hernia repair

AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

VENTRAL REPAIR LAPAROSCOPIC VERSUS OPEN APPROACHES Gamal Al-Shemy, Ahmed M Hassan, Ahmed khyrallh and M. B. Gaber Department of General , Faculty of Medicine, Al-Azhar University ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Background: considered to be the most common complication after abdominal surgery. Thirty percent of patients underwent develop incisional hernia. Ideal repair should be cost-effective with low recurrence rate, minimal operative and post-operative morbidity with short hospital admission and rapid return to casual activities. Objective: The aim of this work is to compare the effectiveness and safety of laparoscopic and open correction of ventral hernia regarding postoperative nausea and vomiting, pain, operative insult, perioperative and postoperative morbidity, hospital stay, and recurrence. Methods: This study has been conducted at Al Azhar University hospitals. It included 100 patients complaining of ventral hernia. Fifty patients underwent laparoscopic repair using Proceed mesh and open repair using polypropylene mesh in another 50 consecutive patients. Results: There were no considerable difference between laparoscopic and open groups concerning comorbidity. The commonest risk factors increasing intra-abdominal pressure was chronic cough followed by constipation. The highest incidence of hernia was incisional hernia. Operative time, laparotomy size, analgesic and antibiotic requirements were in favor of laparoscopic group. Morbidity and recurrences were statistically insignificant between both groups. Bowel sounds, motion, oral feeding, pain, drainage, hospital stay, and return to casual activities were in favor of laparoscopic group. Conclusions: Laparoscopic surgery was effective treatment option offering considerable advantages in contrast to open ventral hernia surgery. It was safe with less complications, early ambulation, shorter hospital admission, early return to casual activities and low recurrence rate. It should be considered as the procedure of choice for ventral hernia repair for straight forward . Open repair should be reserved for more complex hernias. Keywords: ventral hernia, open repair, laparoscopic repair

INTRODUCTION example, the size of the defect or hernia sac, the Ventral hernia is a common surgical problem extent of intra-abdominal adhesions, operative with rise in the repair rate annually. Previously competence, operative time, and costs they were repaired using principals of tension- effectiveness. Surgeons who have not been free suture technique. Due to a high unacceptable familiar with this specific area finds difficulty to recurrence rate this procedure lost popularity. A select the best treatment option. Proper real change in view of repair came with the guidelines resolve this obstacle. 5 advent of mesh hernioplasty. Nowadays it Open repair can be a prime operation with became the commonest procedure for repair of significant morbidity caused by septic ventral hernia. 1 complications. Increasing concern in Ventral Hernia is not classified as one single type laparoscopic surgery and the invention of new of hernia; rather, it is a multilateral term that materials have promoted the adoption of includes a group of hernias that occur in the laparoscopic techniques in repair of ventral anterior abdominal wall. The commonest types hernia. The first laparoscopic repair of ventral are incisional, umbilical, epigastric and Spigelian hernia (LVHR) described by Leblanc and Booth hernia. 2 in 1991. It is depended on the same natural and Ventral and incisional hernia correction is one of surgical bases as the open underlay technique the commonest surgical operations underwent in qualified by Stoppa, Rives et al, and Wantz. clinical practice. Incisional hernia is a well- Nowadays LVHR is being used with growing known long-term morbidity of abdominal frequency even for the treatment of complex surgery. It occurs in 10–30% of laparotomy ventral hernias. Most reports on this subject incisions. 3 Almost half of incisional hernias described minimal postoperative complications, develop through the first two post-operative a shorter recovery period, and a reasonable years after surgery, and 75% after 3 years. The recurrence rate. 6 recurrence of incisional hernia following Ventral and incisional hernias have been an herniorrhaphy is more than 50%. It has been obstacle for surgeons in all ages. Currently, reduced to 10–20% following the introduction of incisional hernias increased in prevalence due to meshes in the field of hernia repair. 4 the very high number of performed The operation for an abdominal wall hernia is in the 21th century. Although minimally hernia hernioplasty in nature. Findings and operation repair and invasive surgery have improved procedures can be extremely complex, for rapidly, surgeons have yet to improve the ideal 125 | P a g e

Gamal Al-Shemy et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

standardized technique that sufficiently and duration of surgery, and postoperatively for decreases postoperative morbidity, as wound intensity of postoperative pain, complications, complications, pain, and recurrence. The length of hospital stay and recurrence within 12 development of and ventral hernia months. repair from simple suture repair to the Methodology: development of prosthetic reinforcement, the Patients with ventral and incisional hernias small difference of minimally invasive hernia repaired with sutures only were excluded from repair from preoperative investigations to the study, as were those with complicated hernia, differences in intraoperative performance should scar sinuses, intra-abdominal pathology be considered. New methods have become more requiring interference, as well as those with skin popular, as primary closure of the defect, infection. All patients underwent routine retrorectus hernioplasty, and concomitant preoperative studies (complete blood count, component separation. Robotics made difficult and renal functions, and blood sugar), abdominal repairs easier. Time and well-designed clinical ultrasonography, chest radiography, and trials will converse if these advances will be a electrocardiogram. Bowel preparation was durable modality for ventral hernia repair. 7 started 48 hours before surgery (for expected any Increased range of wound infection and wound- bowel injury). Prophylactic antibiotic therapy related complications in open prosthetic repair using third-generation cephalosporin and lead to continuing research into the optimal antithrombotic prophylaxis with pressure method of management of ventral hernia which graduated elastic stockings were mandatory. lead the surgeons to accept laparoscopic Nasogastric tube and bladder catheter were used approach. Conventionally, smaller ventral hernia intraoperatively. (<3 cms) has been repaired by open suture Technique of open ventral hernia repair technique repair with its modifications but with a (OVHR): high recurrence ratio of more than 20%. 8 The The used technique of open mesh technique of open repair using prosthetic mesh usually require ventral abdominal hernia was the onlay adequate subcutaneous dissection, raising of technique. Skin scar (if present) was excised, flaps and drain insertion with increased extent of hernial sac was dissected and opened, freeing wound complications as sepsis. 9 adherent viscera, abdominal wall was identified The recent introduction of laparoscopic surgery to free adhesions and detect fascial defects. of ventral hernias is gaining popularity and is Fascial defect was closed with continuous being practiced by many surgeons all over the polypropylene suture if possible (Fig. 1). Onlay world. There is an increasing evidence that polypropylene mesh was fixed to the edges of the laparoscopic repair of PUH is superior to open defect with overlap of 5 cm in all directions with mesh repair regarding operative and interrupted prolene sutures (Fig. 2). Suction postoperative complications, postoperative pain drains was used with subcutaneous and skin and overall morbidity and mortality. 10 Very few closure. studies are available comparing the open versus Technique of laparoscopic ventral hernia laparoscopic mesh repair, most of them are repair (LVHR): retrospective. 11 The patient is placed in the supine position on the The primary objective of the study was to surgical table with the arms extended and the legs compare the early complications of LVHR and extended and abducted. The abdomen was OVHR with mesh prothesis. Secondary prepared, with bladder and gastric objectives were to compare the operative time, decompression. Laparoscopic repairs are length of postoperative hospital stay and performed under general via 10-12 recurrence rate after one year of follow up. mm camera port and two to three 5 mm working ports. A 30-degree scope was used (Fig. 3). The PATIENTS AND METHODS surgeon stands on the right side of the patient for In this prospective comparative study, the defects located on the left side, and for midline outcomes of the 50 cases of laparoscopic ventral and right defects the surgeon stands on the hernia repair will be compared with another 50 opposite position. The video monitor is cases of open repair. The open repairs were positioned in front of the surgeon. A direct cut performed using polypropylene mesh and the down approach is performed for induction of laparoscopic repairs using Proceed mesh. pneumoperitoneum, with 10 mm camera port Patients will be divided into two groups (A and placed as far away from the defect as possible. B), (A- representing open mesh repair and B- After induction of pneumoperitoneum direct laparoscopic repair). Patients of both groups view laparoscope (30o) inserted to facilitate were observed per-operatively for difficulties insertion of the other trocars. 126 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

The number and position of working ports are least 3 to 5 cm, with the anti-adhesive surface individualized according to size, location, and facing the bowel. then individual sutures are number of defects present. In the repair of very brought up through 2 mm incisions in the skin large defects, two working ports for the surgeon with 11 blade at the 4-6 predetermined locations and two for the assistant are usually required. drawn in the pattern on the abdominal wall and Smaller defects such as umbilical and epigastric tied subcutaneously using the suture passer. The hernias can be repaired with only two or three sutures are tied down, with the knots lying in the working ports. The hernia and its contents must subcutaneous tissue. This is repeated with each be viewed from different angles via the working of the 4 to 6 sutures placed in the biomaterial. ports throughout the procedure. One or two of the The process anchors the biomaterial to the entire working ports must be 10 mm to accommodate thickness of the abdominal wall and prevents the 10-mm laparoscope. The specific placement migration of the biomaterial down into the defect of the ports is dependent on the location of the over time. In between the sutures, the peripheral hernia. For midline and ventral hernias, a 10-mm edge of the mesh is tacked into position with 5 camera port is inserted laterally via the open mm tacks (Fig. 6) or stapled with special hernia technique and two 5 mm ports are inserted. stapler. These are placed at 1 cm intervals. Abdominal wall defects are freed of peritoneal Closure of the skin incisions is done without and visceral adhesions (Fig. 4), the surgeon drains. works with dissecting and grasping forceps, and Data collection and analysis scissors. Counter pressure on the outside of the We recorded the following data for analysis: abdominal wall is often very helpful. No patient age, gender, comorbidities, previous cauterization should be used to prevent bowel abdominal operations and previous attempts of wall injury. Hernia contents is reduced and the hernia reconstruction, hernia defects (number defect in the fascia is outlined. A minimum of 3.5 and size), size of the prosthetic mesh, operating cm from the border of the defect should be duration, post-operative pain score, hospital cleared of adhesions. Closure of large hernia admission, complications, and recurrence. At defects is done (Fig. 5) with non-absorbable follow-up assessment (within 12 months), a sutures, even if only a limited closure is possible. clinical examination for complications, hernia Next step is to determine the borders of the recurrence, and pain score also were recorded. hernia, which may sometimes be difficult; once Statistical analysis: Chi-square analysis and the hernia defect has been defined the proper size Fishers exact test were used to compare the of the mesh is determined. This is done by relationships among categorical variables. T-test putting intra-abdominal instrument towards a used to significant different between means. palpating finger on the surface of the abdomen Means of variables for both groups were and marking out the hernia or by insertion of compared. P-value less than 0.05 was considered needles through the abdominal wall and marking to represent statistical significance for all the position of the hernia defect. (Preoperatively comparisons. an attempt should be made to palpate the edges of the defect and trace it on the abdominal wall RESULTS with a marker). Once the hernia is marked out on This study included 100 patients with incisional the skin, the appropriate size of the Proceed mesh or primary ventral hernias. Half of these patients is then cut, leaving a 3 –5 cm cuff or margin were operated upon laparoscopically using lateral to the fascial defect all the way around. Proceed mesh and the other group with open Transfixing horizontal mattresses prolene sutures surgery using polypropylene mesh. As regard to (2/0) are placed around the edge of the patch at 6 demographic data; gender, and defect size were cm interval, the smooth side (which lies against statistically insignificant between the two groups the viscera) is marked, and sutures are placed, whereas age and BMI were statistically higher in tied, and cut (leaving tails approximately 4 to 6 laparoscopic repair group (Table 1). There was inches long) at 4 to 6 spots equidistant around the no considerable difference between both groups entire piece of the biomaterial, and numbered on regarding comorbidity (Table 2). The the prosthetic surface and around the tracked commonest risk factors increasing intra- edge of the patch on the abdominal wall. The abdominal pressure were chronic cough followed mesh is rolled side to side after placing the suture by constipation, these risk factors were ends down in reverse order to facilitate retrieval, statistically insignificant (Table 3). Regarding and the mesh is brought in to the abdomen by types of hernia, the commonest type was using one of the graspers. incisional hernia then , After unrolling the mesh, it should be accurately paraumbilical hernia, and epigastric hernia. Type spread to overlap the edges of the defect by at of hernia were not statistically significant 127 | P a g e

Gamal Al-Shemy et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

between both groups (Table 4). Operative time regard to less perioperative complications, was shorter in laparoscopic repair group than minimal blood loss, and shorter hospital open repair group with significant differences admission. 13, 14 between two groups (p=0.01). Regarding Nowadays, repair of ventral hernia by laparotomy size, it was highly significant laparoscopy is being accepted by most of the between two groups (p=0.001). Analgesic surgeons and patients. Almost all ventral hernias requirements were higher in open repair group can be repaired by laparoscopy, regardless of than laparoscopic group with significant morbid obesity and age group. 15 differences between the two groups (p=0.02). The present study found that age and BMI were Antibiotic requirements were taken for longer higher in laparoscopic repair group with time in open repair group than laparoscopic considerable differences among the two groups group with significant differences between the (p=0.04, 0.012 respectively) while gender and two groups (p=0.01) (Table 5). Complications in wall defect size were insignificant among the two both groups were bleeding, bowel injury, wound groups. In Eker et al study 206 patients were infection, and seroma formation. Recurrence randomized to undergo laparoscopic (99 reported only in one case of open repair. There patients) or open (107 patients) repair of was no statistically significant difference incisional hernia. Both groups were similar in between both groups as regard complications gender ratio, age, and mean body mass index. 12 (Table 6). Sabuncuoğlu et al study included 40 cases First peristalsis and first defecation was earlier in underwent open and laparoscopic procedure for laparoscopic group than open group with incisional hernia, no differences found between significant differences between two groups p the two groups as regard age, and BMI (body =0.01, 0.01 respectively. Regarding time of re- mass index). 16 Another study by Earle et al feeding it was shorter in laparoscopic group than conducted on 426 patients, both groups were well open group with significant differences between matched for age and ASA (American Society of two groups (p=0.01). Regarding post-operative Anesthesiologists) classification. A significantly pain VAS score was higher in open group than higher percentage of women was found in the laparoscopic group with highly significant laparoscopic group (female: male, 1.7:1 lap, differences between two groups (p=0.001). 0.95:1 open). 17 Study of Hussain et al on ventral Duration of drainage was 5.6 ± 4.4 days in open hernia repair with laparoscope involved 29 group and no drain in laparoscopic group women (47.54%) and 32 men (52.45%). The (p=0.0001). Post-operative hospital stay was mean age was 53.42 years (range 39–80 years). longer in open repair with significant differences 18 between two groups (p=0.01). Return to normal The local factors such as the laparotomy incision activities was earlier in laparoscopic group than (site and size), and systemic co-morbidities as open group with significant differences between old age, chronic respiratory disease, diabetes two groups (p=0.01). These data concerning mellitus, malnutrition, chronic steroid usage, and patient's outcome were summarized in Table 7. obesity are the major factors affecting outcome of incisional hernia surgery. 19 Regarding co- DISCUSSION morbidity Bingener et al found that diabetes was Although significant refinements have been the most common co morbidity in the two groups accomplished in the field of incisional hernia with unassuming difference between both groups repair concerning operative modalities and the (p=0.61). 20 In the present study we found that use of mesh prosthesis, recurrence rates remain diabetes (DM) was the commonest co-morbidity elevated (32-63%). hazard factors responsible for in both groups followed by hypertension (HTN) recurrence as size of the hernia, unluckily cannot but with insignificant differences between both be influenced. realization for less invasive and groups (p=0.6 and 0.5 respectively). In Modiya more effective procedures continues. et al study they found that main risk factors in Laparoscopy has proved to be a safe, efficient, both groups was diabetes mellitus (20% of the effective, and less painful technique for many involved patients) followed by smoking (14%), types of surgery and has become the current then hypertension (12%). 21 Morbid obesities, “gold standard” for , for prostatism, chronic cough, wound infection, example. 12 large incision, and malnutrition are the most Laparoscopic repair is exceedingly used and important risk factors for ventral and incisional widely accepted operative procedure. General hernia. The commonest risk factor found in the advances of laparoscopic trends are valid for this present study in both groups was chronic cough group of patients. The short term outcome of followed by constipation, these risk factors were laparoscopic repair is outstanding open repair as statistically insignificant between the two groups 128 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

(p=0.8, 0.6 respectively). In agreement with our controlled study agreed with our result, study Modiya et al found 6 patients (12%) had laparoscopic technique was associated with less chronic cough for which medication started time, reduced postoperative pain, analgesic preoperatively. Cough was controlled with chest needs and antibiotic requirement. 26 Regarding physiotherapy preoperatively. These patients laparotomy size was found to be highly underwent surgery only after they became fit. significant between two groups (p=0.001). Treatment for cough continued postoperatively. Fabozzi et al found highly significant diversity Nine patients (18%) had constipation, they given between both groups regarding laparotomy size. laxatives, stool softeners before and after 27 surgery. Four patients (8%) had prostatism with Analgesic requirements were higher in open dysuria. 21 group than laparoscopic group with significant Regarding types of hernia, the commonest type divergence between both groups (p=0.02), detected was incisional hernia followed by regarding post-operative pain it was higher in umbilical hernia, paraumbilical hernia, and open group than laparoscopic group with highly epigastric hernia with statistically insignificant significant distinction between two groups difference between groups (p=0.168). In (p=0.001). Several randomized trials reported no agreement with our result Hussain et al found variation in postoperative pain after laparoscopic that most common type of hernia was incisional or open incisional hernia renovation. 13, 23, 28 hernia following laparotomy (42%), umbilical Single study reported decreased use of analgesia and paraumbilical (39.34%), spigelian and after laparoscopic surgery. 23 Postoperative epigastric hernia (6.55%). 18 Khan et al agreed suffering following incisional hernia surgery in their study on ventral hernia repairs that both often results from the surrounding tissues not groups were statistically similar in terms of from the hernia itself. Mesh fixation materials, gender, age and types of ventral abdominal e.g., tackers or trans-fascial sutures, are believed hernias. 22 to be responsible for postoperative pain. The In the comparative study of Eker et al between advantages of laparoscopy regarding surgical laparoscopic and open hernia repair regarding wounds and wound pain could possibly be offset duration of operation, laparoscopic repair was by mesh fixation materials such as tackers and shorter than open repair with significant trans fascial sutures. 29 differences between both groups (p=0.01). Eker Antibiotic requirements were higher in open et al found that the mean operation time was surgery than laparoscopic group with presumed significantly longer in the laparoscopic group differences between the two groups (p=0.01). than in the open one (76 minutes’ vs 100 minutes; Wound sepsis following incisional hernia P=0.001). Eight of the 94 patients (8.5%) surgery with implant can be catastrophic, so required conversion to open repair because of antibiotic prophylaxis is mandatory. Deeper technical difficulties. 12 Shorter operative infections have a serious outcome on life quality duration of laparoscopic repair was reported also (occurs in 1–2%). The only prospective, non- in several studies. 13, 14, 23 Other studies comment randomized study reported a reduction in no differences in operative times between both infection rate of 50% in those who were groups. 24, 25 receiving prophylaxis. 30 In small incisional hernia, trocars introduction Malik et al found that the overall incidence of and instruments positioning consume time. complications was considerably higher in group During open technique, hernia is often reduced B with open repair compared to group A with spontaneously. In the laparoscopic technique, laparoscopic repair in the form of (prolonged positioning and fixation of the prosthesis to the ileus, hematoma, intestinal injury, seroma, abdominal wall may be time consuming. A major bleeding during adhesiolysis, wound site factor that might affect time factor in the infection). Recurrence in both groups was laparoscopic repair is extensive adhesiolysis of statistically trivial (p=0.8). Recurrences in group the abdominal wall. Adhesiolysis is necessary for B were seen in cases developed post-operative proper positioning of the mesh and also for sepsis. Recurrences in laparoscopic group detection of any other small hernia or “Swiss- occurred mostly in cases who were operated cheese” defects (multiple small defects). These earlier in the series who had huge hernias. 31 factors or combination of it could explain the Zhang et al agreed with us that there was no longer operative time in some laparoscopic considerable difference between both groups in cases. Performing laparoscopic ventral incisional the incidences of hernia recurrence and other hernia repair in about one hundred minutes is postoperative complications, as well as in reasonable and compatible to data from previous postoperative pain. 32 In contrary Fabozzi et al studies. 12 Porecha et al non-randomized study found that the post-operative morbidity 129 | P a g e

Gamal Al-Shemy et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

rate was 14% in open group and 5% in found that rates of drainage were considerably laparoscopic group. 27 Parmar et al found that lower in the laparoscopic cases than that in the there were 2 patients who developed open ones (laparoscopic 2.6%, open 67.0%, and complications in form of infection and seroma p=0.00001). 32 Fabozzi et al agreed with our formation in open group, while in the result as they found that drainage was longer in laparoscopic group there was a single patient open repair group than in laparoscopic cases as who developed complication in the form of ileus. there were no drain in laparoscopic cases. 27 However, there were no recurrences in any of the Regarding return to normal life activities in our groups. 33 study it was earlier in laparoscopic cases than In a Meta-analysis by Forbes et al, they found no open group with considerable differences variation in complications, such as seroma between both groups (p=0.01). In Modiya et al formation, but there was a trend toward reduced study in laparoscopic surgery 23 patient (92%) hemorrhagic complications and infections returned to their work within 6th to 10th post- requiring mesh removal in the laparoscopic operative day. In open surgery 20 patient (80%) cases. There was also a trend toward greater risk returned to their work within 6th to 10th post- of intestinal damage in this group. Patients who operative day. 21 Olmi et al reported a median performed laparoscopic repair, however, were at return to work of 13 days (6–15) after a significantly lower risk of wound infections laparoscopic surgery compared with 25 days that did not require mesh removal. 34 (16–30) after open surgery (P=0·005). 14 Robbins In the current study post-operative hospital et al showed that the main advantage of this admission was longer in open cases with minimally invasive approach is a decrease in the considerable differences between both groups rate of major wound complications and early (P=0.01). Modiya et al agreed with us that post- return to work. 38 Parmar et al found that patients operative stay was shorter for laparoscopic could return to normal activity in a mean of 3.2 hernioplasty group than open hernioplasty group days in open group and in 2.6 days in (2.7 vs. 4.7 days) and in our study, mean hospital laparoscopic one. Time taken to return to casual admition was 2.0 ± 0.8 days in laparoscopic activity was 8.8 days in open group and 7.8 days hernioplasty group and 3.4 ± 2.2 days in open in the laparoscopic cases. 33 hernioplasty group. 21 Advantages of the Regarding cost effectiveness in our study, it was laparoscopic technique have been assured in found that it is higher in laparoscopic cases than meta-analyses as they showed that duration of open group with considerable differences hospital admission is shorter by 2–3 days and between both groups (p=0.001). Two studies carries lower complication rates. 35, 36 In detected that in the laparoscopic groups, the disagreement to our result Eker et al found that instrument cost was considerably higher, but the the median hospital stay was similar in both overall cost was considerably lower. 39, 40 This groups (3 days [inter quartile range (IQR), 2-4 analysis has assured laparoscopic technique to be days] and 3 days [IQR, 2-5 days] days, cost-effective as compared with non-prosthetic respectively; P=0.5). 12 Several studies recorded repair, when considering earlier resumption to a considerable shorter mean hospital stay after work and decreased recurrences, a fact that laparoscopic repair, with mean stays no longer minimize the cost by 10–15%. 41 than 5.7 days, compared with 10 days for open Other revisions, such as Cochrane et al 42 failed surgery. 13, 37 to provide equally definitive results; however, Regarding time of refeeding in our study we they evidenced the notability of laparoscopy, observed that it was shorter in laparoscopic cases although for short-term studies. These scientists than open ones with considerable differences should facilitate the responsibility of a between both groups (p=0.01). Fabozzi et al professionalized trials before it is funded by the agreed with our result that time of refeeding was health organizations, to obtain a justification of shorter in laparoscopic cases than open ones. 27 resources. It believed that the economic cost of In our study, return of peristalsis and defecation LVHR can be balanced by the merits of were earlier in laparoscopic cases than open laparoscopic surgery in this procedure. In group with considerable differences between comparison to OVHR, LVHR is performed with both groups (p=0.01, 0.01) respectively, this less time, less complications, shorter hospital agree with the study of Fabozzi et al as they stays and there is practically no need for found that peristalsis and defecation was earlier drainage. Wound sepsis will be less and we are in laparoscopic cases than in open ones. 27 hopeful that the upcoming series will ensure less In our study drains were removed after a mean of recurrences for LVHR. All these points make 5.6 ± 4.4 days in open group and no drain in LVHR a cost-effective procedure. 18 laparoscopic group (p=0.0001). Zhang et al 130 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

Other studied showed that laparoscopic Derg. Turkish Surgical Association. procedure carries higher costs than does open 2015;31(3):157–61. repair. Although, it offers superior cost 6. Misiakos EP, Patapis P, Zavras N, Tzanetis P, effectiveness as it entails shorter hospital stay, and Machairas A. Current Trends in decreased morbidity, surely lower mortality, less Laparoscopic Ventral Hernia Repair. JSLS. intensive care needs and less readmissions, and 2015; 19(3): e2015.00048. thus it significantly reduces overall hospital 7. Vorst AL, Kaoutzanis C, Carbonell AM, and costs. 43, 44 Franz MG. Evolution and advances in LVHR has been proved to be efficacious and laparoscopic ventral and incisional hernia safe, with many advantages for the patient repair. World J Gastrointest Surg. 2015; himself and health care providers as compared to 7(11): 293–305. OVHR. Increasing clinical experience and 8. Alexander AM, Scott DJ. Laparoscopic greater adoption of this approach by surgeons ventral hernia repair. Surg Clin North Am. will improve the quality of data available to 2013; 93:1091–110. support its role as the preferred standard 9. Bucher P, Pugin F, Morel P. Single port treatment for this commonly encountered laparoscopic repair of primary and incisional problem. 45 ventral hernia. Hernia. 2009;13(5):569–70. 10. Cassie S, Okrainec A, Saleh F, Quereshy FS, CONCLUSION Jackson TD. Laparoscopic versus open Laparoscopic ventral hernia repair is a successful elective repair of primary umbilical hernias: line of treatment offering considerable short-term outcomes from the American advantages compared with open surgery. It is College of Surgeons National Surgery safe and results in short hospital admission, Quality Improvement Program. Surg Endosc. fewer complications, early ambulation, early Vol. 28. US: Springer; 2014. pp. 741–46. return to work, and less recurrence. There is 11. Othman IH, Metwally YH, Bakr IS, Amer agreement that it should be the procedure of YA, Gaber MB, Elgohary SA. Comparative choice for repair of ventral hernia. The study between laparoscopic and open repair laparoscopic approach is more suitable for of paraumbilical hernia. J Egypt Soc straight forward hernias, while open repair Parasitol. 2012;42(1):175–82. should be reserved for more complex hernias. 12. Eker H, Hansson B M, Buunen M. Laparoscopic ventral hernia repair represents Laparoscopic vs. open incisional hernia acceptable surgical option that can be offered by repair: a randomized clinical trial. JAMA surgeons skillful in sophisticated laparoscopic Surg. 2013; 148:259-63. techniques with access to high-technology 13. Misra MC, Bansal VK, Kulkarni MP, Pawar equipment. DK. Comparison of laparoscopic and open repair of incisional and primary ventral REFERENCES hernia: results of a prospective randomized 1. Seker G, Kulacoglu H, Öztuna D, Topgül K, study. Surg Endosc. 2006; 20:1839–45. Akyol C, Çakmak A. Changes in the 14. Olmi S, Scaini A, Cesana GC, Erba L, Croce frequencies of abdominal wall hernias and E. Laparoscopic versus open incisional the preferences for their repair: a multicenter hernia repair. Surg Endosc. 2007; 21: 555– national study from Turkey. Int Surg. 559. 2014;99(5):534–42. 15. Porecha M, Mehta S, Thanthvalia A. 2. Luijendijk R, Hop W, Van den Tol MP. A Comparative Study of Laparoscopic versus comparison of suture repair with mesh repair Open Ventral Hernia Repair. The Internet for incisional hernia. N Eng J Med. 2000; Journal of Surgery. 2009; 22 Number 2. 343:392–8. 16. Sabuncuoğlu M Z, Benzin M F, Dandin O. 3. Bloemen A, van Dooren P, Huizinga Laparoscopic and open incisional hernia BF. Randomized clinical trial comparing repair: A prospective randomized study. Am polypropylene or polydioxanone for midline J Exp Clin Res. 2015;2(3):121-126. abdominal wall closure. Br J Surg. 2011; 17. Earle, D., Seymour, N., Fellinger, E. Surg 98:633–9. Endosc (2006)20:71. doi:10.1007/s00464- 4. Shell DH, de la Torre J, Andrades T, Vasconez 005-0091-z LO. Open repair of ventral hernia 18. Hussain A, Mahmood H, Nicholls J. incisions. Surg Clin North Am. 2008; 88:61– Laparoscopic ventral hernia repair. Our 83. experience of 61 consecutive series: 5. Kulaçoğlu H. Current options in umbilical Prospective study. International Journal of hernia repair in adult patients. Ulus cerrahi Surgery. 2008; 6.15-19. 131 | P a g e

Gamal Al-Shemy et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

19. Rudmik LR, Schieman C, Dixon E. 30. Rios A, Rodriguez J M, Munitiz V. Antibiotic Laparoscopic incisional hernia repair: a prophylaxis in incisional hernia repair using review of the literature. Hernia. 2006; 10: a prosthesis. Hernia. 2001; 5:148-52. 110–9. 31. Malik AM. Laparoscopic versus open repair 20. Bingener J, Buck L, Richards M. Long-term of para-umbilical hernia. Is it a good Outcomes in Laparoscopic Vs Open Ventral alternative? JPMA. 2015; 65: 865. Hernia Repair. Arch Surg. 2007; 142:562-7. 32. Zhang Y, Zhou H, Chai Y. Laparoscopic 21. Modiya Y, Parmar K, Panchal B. Versus Open Incisional and Ventral Hernia Comparative Study of 25 Cases Open Vs Repair: A Systematic Review and Meta- Laparoscopic Ventral Abdominal Hernia analysis. World J Surg. 2014; 38:2233–40. Meshplasty. IJSR. 2014; 3.10. 33. Petro CC, Como JJ, Yee S. Posterior 22. Khan J S, Qureshi U, Farooq U. The component separation and transverses Comparison of Open and Laparoscopic abdominis muscle release for complex Hernia Repairs. J Postgrad Med Inst. 2012; incisional hernia repair inpatients with a 26(4): 397-401. history of an open abdomen. J Trauma Acute 23. Navarra G, Musolino C, De Marco ML, Care Surg. 2015; 78:422–9. Bartolotta M, Barbera A, Centorrino T. 34. Forbes SS, Eskicioglu C, McLeod R, Retromuscular sutured incisional hernia Okrainec A. Meta-analysis of randomized repair: a randomised controlled trial to controlled trials comparing open and compare open and laparoscopic approach. laparoscopic ventral and incisional hernia Surg Laparosc Endosc Percutan Tech. 2007; repair with mesh. BJS. 2009; 96:851–8. 17: 86–90. 35. Sains PS, Tilney HS, Purkayastha S. 24. Barbaros U, Asoglu O, Seven R. The Outcomes following laparoscopic versus comparison of laparoscopic and open ventral open repair of incisional hernia. World J hernia repairs: a prospective randomized Surg. 2006; 30:2056–64. study. Hernia. 2007; 11: 51–56. 36. Sajid M, Bokhari S, Mallick A, Cheek E, 25. Muysoms F, Vander Mijnsbrugge G, Baig M. Laparoscopic versus open repair of Pletinckx P. Randomized clinical trial of incisional/ventral hernia: a metaanalysis. Am mesh fixation with “double crown” versus J Surg. 2009; 197:64–72. “sutures and tackers” in laparoscopic ventral 37. Aher CV, Kubasiak JC, Daly SC. The hernia repair. Hernia. 2013; 17:603–12. utilization of laparoscopy in ventral hernia 26. Parshikov V.V., Fedaev А.А. Abdominal repair: an update of outcomes analysis using Wall Prosthetic Repair in Ventral and ACS-NSQIP data. Surg Endosc. 2015; Incisional Hernia Treatment: Classification, 29:1099–104. Terminology and Technical Aspects 38. Robbins SB, Pofahl WE, Gonzalez RP. (Review) Sovremennye Tehnologii v Laparoscopic ventral hernia repair reduces Medicine. 2015; 7(2):138-52. wound complications. Am Surg. 2001; 27. Fabozzi M, Allieta R, Grimaldi L. Open vs 67:896–900. laparoscopic repair of abdominal hernia: a 39. Lomanto D, Iyer S, Shabbir A, Cheah W. case control study in over 60 years old Laparoscopic versus open ventral hernia patients. BMC Surgery. 2013; 13(Suppl 1): mesh repair: a prospective study. Surg A19. Endosc. 2014; 20:1030–5. 28. Muysoms F, Miserez M, Berrevoet F, 40. Vale L, Ludbrook A, Grant A. Assessing the Campanelli G, Champault G, Chelala E, cost and consequences of laparoscopic vs Dietz U, Eker H, El Nakadi I, Hauters P, open method of groin hernia repair: a Hidalgo Pascual M, Hoeferlin A, Klinge U, systematic review. Surg Endosc. 2003; Montgomery A, Simmermacher R, Simons 17:844–9. M, S ´ mietan´ski M, Sommeling C, Tollens 41. Fazzio Jr FJ. Cost-effective, reliable T, Vierendeels T, Kingsnorth A. laparoscopic hernia repair. A report of 500 Classification of primary and incisional consecutive repairs. Surg Endosc. 2002; abdominal wall hernias. Hernia. 2009; 16:931–5. 13:407– 14. 42. Sauerland S, Walgenbach M, Habermalz B. 29. Topart P, Vandenbroucke F, Lozac’h P. Laparoscopic versus open surgical Tisseel versus tack staples as mesh fixation techniques for ventral or incisional hernia in totally extraperitoneal laparoscopic repair repair. Cochrane Database Syst Rev. 2011; of groin hernias: a retrospective analysis. 3:CD007781. Surg Endosc. 2005; 19(5):724-7.

132 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

43. Beldi G, Ipaktchi R, Wagner M. hernia (International Endohernia Society). Laparoscopic ventral hernia repair is safe and Surg Endosc. 2015; 29:289-321. cost effective. Surg Endosc. 2006; 20:92–95. 45. Kingsnorth A, Banerjea A, Bhargava A. 44. Bittner R, Montgomery M A, Arregui E. Incisional hernia repair – laparoscopic or Update of guidelines on laparoscopic (TAPP) open surgery? Ann R Coll Surg Engl. 2009; and endoscopic (TEP) treatment of inguinal 91: 631–6.

Figure 1. Closure of the fascial defect.

Figure 2. Onlay mesh positioning and fixation.

Figure 3. Port sites in large ventral hernia.

133 | P a g e

Gamal Al-Shemy et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

Figure 4. Adhesiolysis in LVHR a) Incarcerated segment of greater omentum; b) Reduction of hernia sac contents; c) Dense adhesions between small bowel and abdominal wall; d) Sharp dissection between prosthetic material and underlying viscus.

Figure 5. Closure of the hernial defect.

Figure 6. Tacking of the mesh. Table 1. Demographic data of both groups. Laparoscopic repair Open repair Test of P (n=50) (n=50) sig. value No. % No. % Gender Male 26 52 22 44 0.000 1.000 Female 24 48 28 56 Age (years) 58.4 ± 4.4 48.2 ± 3.6 t=2.12* 0.04* Defect size (cm) 10.2 ± 8.6 11.8 ± 6.4 t=0.45 0.56 BMI (kg/m2) 28.6 ± 4.4 26.8 ± 2.8 t=2.60* 0.012* 134 | P a g e

AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

Table 2. Comorbidity of both groups. Laparoscopic repair Open repair (n=50) P Comorbidity (n=50) value No. % No. % Diabetes 8 16 10 20 0.6 Hypertension 5 10 8 16 0.5 Ischemic heart disease 2 4 1 2 0.8 Table 3. Risk factors of both groups Laparoscopic repair Open repair (n=50) P Risk factors (n=50) value No. % No. % Chronic cough 7 14 6 12 0.8 Constipation 4 8 6 12 0.6 Table 4. Types of hernia in both groups. Laparoscopic repair (n=50) Open repair (n=50) P Types of hernia No. % No. % value Incisional 32 64 38 76 Umbilical 10 20 6 12 0.168 Paraumbilical 5 10 4 8 Epigastric 3 6 2 4 Table 5. Comparison between the two groups according to different parameters Laparoscopic Open repair P repair (n=50) (n=50) Mean operative time (min) 96 ± 14.4 128 ± 16.8 <0.01 Laparotomy size (cm) 0.5 - 1 14 ± 8 <0.001 Mean analgesic requirements (days) 3 ± 1.5 6 ± 3.4 <0.02 Mean antibiotic requirements (days) 2 ± 1.2 6 ± 3.6 <0.01 Table 6. Comparison between the two groups as regard complications. Laparoscopic repair Open repair (n=50) P Complications (n=50) Value No. % No. % Bleeding 4 8 4 8 1.0 Bowel injury 0 0 2 4 0.4 Wound infection 2 4 6 12 0.3 Seroma formation 4 8 7 14 0.5 Recurrence 0 0 1 2 0.6 Table 7. Patient's outcome in both groups. Laparoscopic Open repair P Test of sig repair (n=50) (n=50) Value Intestinal sounds (days) 1.0 ± 0.4 1.8 ± 0.8 t=3.246 <0.01 Start of oral feeding 1.0 ± 1.4 1.8 ± 1.6 <0.01 Postop. pain score (VAS) 1.4 7.8 <0.001 First defecation (days) 1.4 ± 0.8 2.2 ± 1.4 t=2.469 0.01 Duration of drainage (days) - 5.6 ± 4.4 <0.0001 Postop. hospital stay (days) 2.0 ± 0.8 3.4 ± 2.2 <0.01 Normal activities (days) 10.0 ± 6.2 18.0 ± 8.4 <0.01

135 | P a g e

Gamal Al-Shemy et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 2

مقارنة اصالح الفتق البطنى بمنظار البطن او الفتح جمال الشيمى - احمد حسن - أحمد خير هللا ، م. ب. جابر قسم الجراحة العامة - كلية الطب - جامعة األزهر ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ نبذة مختصرة الخلفية: يعتبر الفتق الجراحي من أكثر المضاعفات شيو ًعا بعد جراحة البطن. ثالثون في المئة من المرضى الذين خضعوا لفتح البطن معرضون للفتق الجراحي. يجب أن يكون اإلصالح المثالي فعاال من حيث التكلفة مع انخفاض معدل االرتداد ، والحد األدنى من المضاعفات اثناء وبعد الجراحة مع حجز قصير بالمستشفى والعودة السريعة إلى األنشطة االعتيادية. الهدف: الهدف من هذا العمل هو مقارنة فعالية وسالمة اصالح الفتق البطنى بمنظار البطن اوالجراحة المفتوحة فيما يتعلق بالغثيان والقيء بعد الجراحة ، واأللم ، ونتائج الجراحة، والمضاعفات اثناء وبعد الجراحة ، وفترة اإلقامة في المستشفى ، وارتداد الفتق. المرضى والطرق: أجريت هذه الدراسة في مستشفيات جامعة األزهر. شملت 100 مريض يشكون من فتق بطني. خضع خمسين مريضا لإلصالح بمنظار البطن باستخدام شبكة بروسيد )ثنائية الوجه( واإلصالح بالجراحة المفتوحة باستخدام شبكة البولي بروبلين في 50 مريضا آخر على التوالي. النتائج: لم يكن هناك فرق كبير بين اصالح الفتق البطنى بمنظار البطن اوالجراحة المفتوحة فيما يتعلق بالمضاعفات. كانت عوامل الخطورة األكثر شيوعا لزيادة الضغط داخل البطن السعال المزمن يليها اإلمساك. كان أكثر انواع الفتق البطنى الفتق الجراحي. وكان وقت الجراحة ، وحجم جرح البطن ، واالحتياج الى المسكنات والمضادات الحيوية في صالح مجموعة المنظار. كانت المضاعفات وارتداد الفتق غير ذات داللة إحصائية بين المجموعتين. كانت أصوات األمعاء ، والتغوط ، والتغذية الفموية ، واأللم ، والدرنقة ، واإلقامة في المستشفى ، والعودة إلى األنشطة االعتيادية لصالح مجموعة المنظار. االستنتاج: كان خيار الجراحة بالمنظار فعال ويوفر مزايا كبيرة على النقيض من جراحة الفتق بفتح البطن. كانت آمنة مع مضاعفات أقل ، وحركة مبكرة للمرضى ، وحجز بالمستشفى لفترة اقصر ، والعودة في وقت مبكر إلى األنشطة االعتيادية وانخفاض معدل ارتداد الفتق. ينبغي اعتبار الجراحة بالمنظار اإلجراء المفضل إلصالح الفتق البطني البسيط. ويجب االخذ باإلصالح عن طريق فتح البطن للفتق األكثر تعقيدًا. الكلمات الرئيسية: الفتق البطني ، اإلصالح بفتح البطن ، اإلصالح بالمنظار

136 | P a g e